South West Obstetricians & Gynaecologists Society Meeting held at Plymouth Medical Centre on 18 th May 1990 ALTERNATIVES TO EXAMINATION UNDER ANAESTHESIA IN THE STAGING OF CERVICAL CARCINOMA

ing radiation and is inexpensive. Vaginal scanning in the sagittal plane images the uterine body and cervix, and determines vaginal and bladder invasion. Transverse plane transrectal scanning allows visualisation ol' the cervix, its parametrium, and the rectal wall. The normal parametria image as a crescent interrupted centrally by the cervix. In benign inflammatory parametritis, a transient smooth dilatation occurs with maintenance of the cervix

EUA findings are discordant with those at staging laparotomy in 39% of cases (Averettem 1972): parametrial assessment is particularly poor.
Vaginal and rectal ultrasound offer an alternative which is well tolerated, requires no anaesthesia, does not utilise ionising radiation and is inexpensive.
Vaginal scanning in the sagittal plane images the uterine body and cervix, and determines vaginal and bladder invasion.
Transverse plane transrectal scanning allows visualisation ol' the cervix, its parametrium, and the rectal wall. The normal parametria image as a crescent interrupted centrally by the cervix. In benign inflammatory parametritis, a transient smooth dilatation occurs with maintenance of the cervix in the midline.
In malignant invasion there is irregular dilatation of the parametrium with shift of the cervix from the midline to the aliected side.
Cervical volume may be determined by 3-plane measurement.
Parametrial cytology may be determined by fine needle aspiration under ultrasound control. 102 patients were studied. Validation against surgical pathological speciments demonstrates a positive predictive value of 98% in the assessment of parametrial invastion.
(Magnetic Resonance Imaging performed well in parametrial assessment. It has particular value in detecting recurrence, but is costly. The use of CT scanning should be confined to examination of the large tumour and para aortic lymph nodes. shown that single spiral electrodes produce the best quality ECG signals thus are most suitable for data collection. The filter characteristics of the processor to be used have been validated and software has been developed to enable both the raw ECG and patient data to be collected onto an optical disc storage system. The relationships between the ECG vari-ables, antenatal and intrapartum events and eventual outcome will be investigated. Expert systems technology will be used to develop a portable, intelligent fetal monitor to provide consistent, objective information on fetal condition in labour. THE  Supraphysiological plasma oestradiol levels and prolonged endometrial stimulation, lasting many months after cessation of treatment, have been reported in women following repeated oestradiol implants. It has also been reported that prolonged exposure to oestrogens increases the risk of carcinoma in the postmenopausal breast. One hundred women receiving oestrogen implants were followed for 12 months. At every visit each woman completed a "graphic rating scale" (GRS) recording severity of symptoms traditionally related to oestrogen deficiency. Venous blood was taken for asessment of plasma oestradiol and any previous implant therapy recorded. GRS scores failed to correlate with plasma oestradiol values. There was a strong positive correlation between plasma oestradiol and total number of implants received, 42% of women who had received 4 or more implants had plasma oestradiol levels between 700 and 1500 pmols/1. Higher values were more common when implants were administered more frequently and in larger doses. Plasma oestradiol levels reported in this study represent trough values. Post implant peak values would be significantly higher. If supraphysiological plasma oestradiol levels and their potential hazards are to be avoided regular monitoring is required. As traditional symptoms are an unreliable indicator of plasma oestradiol levels, it is suggested that all women receiving 4 or more implants are monitored by regular blood sampling. Attempts should be made to reduce both implant dosage and frequency in women embarking on long term therapy.

Plymouth General Hospital
The aetiology of the unstable bladder (D.I.) remains unknown. Treatment is often unsatisfactory. The effect of emotions on the lower urinary tract has been well documented. Support for a possible psychosomatic aetiology in D.I. comes from well-known clinical findings, such as provocative stimuli (e.g. sound of running water), psychological questionnaire studies, the high placebo response from drug trials and the objective improvement from "psychological" treatments.
As psychological factors are probably implicated, bladderdrill, biofeedback, hypnosis, acupuncture and psychotherapy have been tried.
Results of bladder-drill are good in the short-term but in the long-term show a high relapse rate.
Hypnosis is a form of unconscious bladder re-training. Our work showed good results initially but at two years there was also a high rate of relapse. Attempts to prevent relapse by using casette tapes were ineffective. Similar outcomes have been noted with biofeedback and psychotherapy.
In summary, patients with an unstable bladder should have known causes e.g. a neuropathy or outlet obstruction excluded by history, examination and investigations, including Urodynamics.
Treatment involves a good Doctor/Patient relationship allied to psychotherapy, bladder-drill and drug therapy. The patient is monitored as an outpatient initially. If there is no response then in-patient treatment is indicted. If this fails, then hypnotherapy and/or biofeedback should be tried and if successful should be continued indefinitely to prevent relapse.
Only when all this has failed and the symptoms are severe does one consider surgery e.g. "Clam" ileocystoplasty. This prospective Study was designed to evaluate out-patient hysteroscopy using para-cervical block. Over two years 328 patients underwent diagnostic hysteroscopy under local anaesthesia. A hysteroscopic examination was performed in an out-patient suite specially prepared lor this procedure and thirty minutes were allocated to each examination. A para-cervical or intra-cervical block ol 4 mis Lignocaine 1% was injected via a dental syringe into the cervix. A rigid 4 fliillimeter diagnostic hysteroscope was passed, lacilitated by carbondioxide uterine insufflator. A thorough examination and assessment of the endometrial cavity was made and if appropriate, an endometrial biopsy was taken by either Acurette or fine curette. The level ol pain and discomfort experienced during the examination was matched to one of fiye categories, from 1 intolerable pain, through to 5 which was easily acceptable discomfort. 320 patients were included in the Study with a medium age of 49 years. 38% of the patients were referred for post menopausal bleeding and 55% for dysfunctional uterine bleeding. The examination was successful in 314 of 328 cases. Failure was usually due to cervical stenosis or cervical canal obstruction. No abnormality was detected in 50% of the cases. Fibroid or endometrial polyps were found in 17% and suspected neoplasia 8%. In 20% atrophic endometrium was visualised. In 49 patients a second examination under general anaesthesia was performed. In 35 cases this was for surgical polypectomy. Five cases were suspected malignancy and inadequate biopsy were included, and two of these showed carcinoma of the endometrium. Two showed glandular hyperplasia and one was normal. Nine additional cases were included due to poor visualisation of the cavity and this group included one malignancy. Fifty-five percent of the histology was normal. Endometrial hyperplasia was found in 5% and endometrial malignancies in 4%. Hysteroscopic and histological findings showed good correlation. However, in three cases suspected neoplasia was not confirmed histologically.
Most women found the procedure acceptable, nd only five found it intolerable. No compficationsiittrrbuted to the procedure occurred, and none required admission after hysteroscopy. The side effects were mild and transient and included abdominal cramps, shoulder tip pain, and vagal attacks in two women. Two patients experienced severe discomfort, such that the procedure was abandoned.
These data suggest that out-patient diagnostic hysteroscopy under local anaesthesia is a well tolerated procedure which considerably reduces the need for hospital admission. It provides early investigation for patients with a variety of gynaecological disorders at low cost and with minimal facilities. To the best of our knowledge, no malignancy has been overlooked in any of the 328 patients undergoing this examin- Since the isolation of progesterone in 1934, studies have shown that it is indispensable for the formation of secretory endometrium and hence nidation and implantation. It also appears to maintain uterine quiescence as shown by Csapo (1973). The antiprogestin RU486 is a progesterone and glucocorticoid receptor antagonist synthesised in 1978 in the laboratories of the French company Roussel Uclaf. Studies using RU486 alone as an abortil'acient have demonstrated a complete abortion rate of around 61% in women up to 56 days gestation. However RU486 also sensitizes the uterus to the action of exogenous prostaglandins, and the addition of a subtherapeutic dose of exogenous prostaglandin gives an abortion rate of 95-100%.
Ru486 increases uterine activity in vivo and also increases endometrial prostaglandin production in vitro. In studies using RU486 with or without the prostaglandin synthetase inhibitor indomethacin, we have shown that RU486 in vivo increases the ability of the endometrium to generte prostaglandins and increases uterine activity. The concurrent addition of indomethacin inhibits prostaglandin production by the endometrium but fails to inhibit the increase in uterine activity. This suggests that factors other than an increase in prostaglandin production are responsible for the increase in uterine contractility seen after RU486. The events leading up to the Armada from the first decades of the sixteenth century were described. Sectarian division split Christian Europe, with hideous outrages perpeterted on each other by Catholic and Protestant regimes. International tensions were fuelled by the piracy of English adventurers such as Drake against Spanish possessions and treasure ships in central and South America. Provoked beyond measure, Philip's divine mission to rid England of the Protestant 'usurper' Elizabeth, was given temporal legitimacy through his earlier marriage to Elizabeth's predecessor, Queen 'Bloody' Mary Tudor. The roles of two great Devon seadogs Drake and Hawkyns were examined to disentangle fact from fiction. The failure of the Spanish Armada to invade England resulted as much from ill luck and a fatally flawed strategy, as from the tactical brilliance of the English. Of the 30,000 who set out from Spain, only 10,000 returned ? the rest perished from disease, starvation and drowning on the long journey home. The ten days of skirmishes in the English Channel were curiously inconclusive. From the failure of Philip's illconceived 'Enterprise of England' can be traced the slow decline of Spain's influence and the establishment of England's confidence as a maritime power, laying the foundations of the British Empire.
A single gold ring recovered in the 1960's from one of the Armada wrecks on the coast of Ireland, was a keepsake from a lover. It is inscribed 'No tengo mas que dar te': I have nothing more to give thee. A poignant memorial to all those caught up in the lunacy of international conflict.